In other areas of the country, paramedics may be trained as "critical care paramedics" and have very similar training to what an RN learns in the ICU setting. These EMS services don't require a nurse during those critical transports, and they'll use whatever ambulance they are in for the shift to accomplish the critical care transport. I assume that is what is done in your area of the country. I hope that made sense. this is also similar in my area of indiana. The paramedics at my ambulance service are all trained as critical care paramedics so as to save money by not needing a ICU nurse on alot of the critical hospital transfers. Which would get very expensive since I live in a rural area and anything serious has to be flown out or takin to Indianapolis code 3 in a critical care truck.